ASHP InterSections ASHP InterSections

July 30, 2014

Significant Changes Ahead for ASHP Residency Accreditation

Filed under: Current Issue,From the CEO,Residents,Specialties — Kathy Biesecker @ 4:09 pm
Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

I would like to update you on several initiatives in pharmacy residency accreditation that are underway. We are working on improving the residency accreditation process. This includes streamlining accreditation standards, taking a new look at how accreditation site visits are structured, and making improvements to our electronic systems.

Residency sites can expect to see substantial changes in the PGY1 accreditation standard, making the standard more relevant to pharmacy practice today and in the future. The new draft simplifies and reduces the number of goals and objectives to be achieved. While the current standard has a total of 23 goals and 66 objectives, the new draft standard has 9 goals and 26 objectives.

With the new standard, the value and functionality of the Residency Learning System (RLS) will be re-assessed, and a decision will be made regarding its future use. The Commission on Credentialing and the Accreditation Services staff are working to finalize this draft, and we hope to have the document reviewed by the Board of Directors in September.

In addition to this new standard and in response to many who have provided comments regarding the residency survey process, we are initiating a comprehensive review of our accreditation survey process. This review will be led by ASHP Vice President for Accreditation Services Janet Silvester, along with the Commission on Credentialing. This comprehensive review will include input from residency preceptors and program directors. We want to ensure an effective and efficient program review process for sites, preceptors, residents, and surveyors. Most importantly, the accreditation process should have a strong focus on outcomes of the residency learning experience and of the patient care delivered.

I am also happy to report that our Accreditation Services Office will be changing to meet additional demands with the incorporation of new automation and technology applied to the accreditation process. This will include the pre-survey self-assessment, the survey report, and electronic transfer of most, if not all, documents. These changes will be progressively implemented with the new standard.

ResiTrak and PHORCAS (Pharmacy Online Residency Centralized Application Service) are both going to change notably as well. ResiTrak is being redesigned based on recommendations from the ResiTrak users group, and PHORCAS will gain new functionality to assist programs and applicants in the pre- and post-match process. ASHP is working diligently to ensure additional consistency across all of our surveyor staff. Thus, we will be reviewing the residency accreditation survey process to ensure that it contributes to optimal residency training, promotes positive outcomes of care, and is effective and efficient.

Lastly, I would like to update you on progress in our ability to meet our goal of providing residency training for all new graduates who provide direct patient care by the year 2020. One current barrier to this vision is the gap between residency applicants and available positions.

Even though nearly 1,000 new residency positions were added in the last three years, in 2014 we had approximately 1,700 applicants who did not match. We will continue to focus on expanding residency capacity and look at enhanced models for residency training to assist sites in starting new programs and expanding existing ones. This applies to both PGY1 and PGY2 specialty training. Currently, we have 1,054 PGY1 programs and 660 PGY2 specialty programs, which have more than 3,600 positions available.

I hope that these and other planned changes are welcome advancements. Please do not hesitate to contact Janet Silvester, or members of the Accreditation Staff or Commission on Credentialing with your additional thoughts and ideas.

Remember, our National Pharmacy Preceptors Conference will be held on Aug. 20-22, 2014, in Washington, D.C., and we hope to see you there!

July 22, 2014

ASHP Members Offer Special Expertise to Med-Use Panels

ASHP members are contributing pharmacists's point of view to a number of national healthcare quality efforts.

ASHP members are contributing pharmacists’s point of view to a number of national healthcare quality efforts.

MEASURING, MONITORING, AND IMPROVING PATIENT CARE is becoming increasingly important in today’s healthcare environment, and the opportunity for pharmacists to influence the quality measures that are used has never been greater.

Multi-stakeholder groups such as the National Quality Forum (NQF) are a vital part of this process, endorsing standards for performance measurement and validating quality measurements used in federal payment programs. Through ASHP’s Quality Advocates, pharmacist participation in these groups is helping to shape the reimbursement landscape and improve patient care.

“Our members help build consensus in the rigorous environment of the steering committees,” said Shekhar Mehta, Pharm.D., M.S., ASHP’s director of clinical guidelines and quality improvement. “They assess the feasibility, reliability, validity, and scientific acceptability of proposed measures, and other committee members value pharmacists’ ideas on how a given measure could be implemented in real practice.”

Immediate Impact

It didn’t take long for Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, clinical pharmacist consultant at SHG Clinical Consulting and the IPhA’s Patient Self-Management Program in Springfield, Ill., to have an impact on NQF’s endorsement process. She began her two-year term on the Endocrine Steering Committee in January, and she has already provided influential feedback on several measures that address drug adherence. Haydon-Greatting partnered with another committee member, a researcher for a pharmaceutical company, to explain ways of calculating adherence to other committee members.

Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, is working on drug adherence measures as part of the NQF’s Endocrine Steering Committee.

“Clinicians such as nurse practitioners want to know how they can ensure that patients are adhering to the prescriptions they write. They generally don’t know if the patient has been taking medications until the next visit, so they want to know how to create [patient] accountability,” Haydon-Greatting said.

“I made the point that pharmacists can see if patients are filling their prescriptions, and that pharmacists can take the lead on tracking that kind of data.”

Haydon-Greatting drew upon her work as pharmacy network coordinator for Taking Control of Your Health, an offshoot of the Diabetes 10-City Challenge in which pharmacists lead treatment programs for employees with diabetes.

“We have electronic medical records and web-based programs, and I was able to speak from experience and say that once you have those, the data is already there.”

She added that her input has not only been well-received, but actively solicited by other members of the group. “There are over 20 physicians on this committee, and once they found out I was the only pharmacist, every time a question came up about medication use or adherence, all heads turned to me.”

Winning Recognition

Haydon-Greatting’s experience may be testimony to how far pharmacists have come in the eyes of other clinicians. Five years ago, Steven M. Riddle, Pharm.D., BCPS, FASHP, director of clinical development for Pharmacy OneSource/Wolters Kluwer Health in Seattle, had to prove his mettle on the NQF’s Ambulatory Care Steering Committee.

Steven M. Riddle, Pharm.D., BCPS, FASHP

Steven M. Riddle, Pharm.D., BCPS, FASHP

“I was on a panel with some well-known people in positions of authority [in their fields], national leaders who were not easy-going, subtle folks. There I was, [then] just a pharmacist from the University of Washington to them, and they challenged me. I had to earn a little credibility,” Riddle said.

He earned their respect by applying his background and training as a pharmacist to the four key criteria the committee used in deciding whether to endorse a measure—its importance, scientific acceptability, usability, and feasibility.

“Pharmacists are trained in evidence-based medicine, understanding the trials, and determining whether the clinical and technical evidence is valid. That’s part of what [NQF Committees] must look at when evaluating a measure,” said Riddle, who served until recently the chair for ASHP’s Section of Ambulatory Care Practitioners. “There were times when I swayed opinion by going back to the four criteria, but it was tricky to negotiate. For example, something could be highly valuable but completely unfeasible.”

As with Haydon-Greatting, once Riddle demonstrated his knowledge, the other committee members were quick to tap him for input. “I was able to hold my own and bring forward my concerns. Then when they had questions about medication use, they would ask me, ‘Well, what do you think, Steve?’ ”

Looking to the Future

Pharmacists have their work cut out for them on these committees, said Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS, VISN 21 Pharmacy Executive at the Department of Veterans Affairs in Reno, Nev. She encourages young pharmacists to look into systems development and healthcare analytics, noting how her experience with the VA’s clinical data warehouse proved invaluable when she served on the NQF’s Medication Management Steering Committee in 2009.

Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS

Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS

“The VA is a data utopia. Knowing that I came from an environment with a mature electronic medical record system, the committee members were willing to give me a bit of a bye in presenting my views on evaluating and collecting health data,” she said.

“As electronic medical records become the norm, and the business of metrics and quality measurements becomes more important, the ability to load data sets and analyze the information will become essential.”

Recognizing the need for pharmacist representation in groups like the NQF, ASHP is bolstering efforts for more participation among its membership.

“We’ve been trying to bring more pharmacists into the various committees,” said Christopher J. Topoleski, ASHP’s director of federal regulatory affairs. “Younger pharmacists are more and more interested in informatics. They’re a tech-savvy generation, and as they get experience in using data in the implementation of quality improvement measures, we’ll have a larger crop of people to choose from.”

–By Terri D’Arrigo

Editor’s note: The above story is the second part of a two-part series on how ASHP members are influencing and steering national quality measures. Click here to read the first story.

July 21, 2014

Provider Status Update: Progress Continues to Be Made

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Let me just start by saying that this has been a great summer on all fronts, not the least of which being the pharmacy profession’s stellar efforts to achieve provider status for the patients we serve. In fact, provider status was at the top of the list of discussion points when ASHP Vice President Kasey Thompson and I met with White House staff last week to talk about expanded roles for pharmacists.

Our provider status campaign is making great progress.  To date, we have 71 Congressional co-sponsors for our provider status bill, H.R. 4190.  What’s even more amazing is that support for H.R. 4190 is truly bipartisan with an almost 50-50 split between Democrat and Republican co-sponsors.  What a great story to tell that pharmacists seeking to improve patient care were able to bring a highly divided Congress together around a common cause.

Another exciting story to tell about H.R. 4190 is that two of the co-sponsors are physicians.  I think it’s safe to say that the value pharmacists bring to the patient care team is proven and is widely recognized and accepted by other providers and the public.

We have an exceptional coalition working hand-in-hand to tell the compelling story of what pharmacists can do to improve the lives of patients, and how provider status would improve patient access to pharmacists.  The Patient Access to Pharmacists Care Coalition (PAPCC) is comprised of most of the major pharmacy professional organizations along with a host of others, including the largest chain pharmacies and their respective trade organization.

But, it’s not just our efforts in Washington, D.C., that are making the difference.  ASHP members from all over the country have been writing thousands of letters to their members of Congress and giving to the ASHP Political Action Committee (PAC) in record numbers.  Further, they have been meeting with their congressional representatives and senators when they are back in the state, hosting practice site visits, attending political fundraisers, writing opinion pieces in their local newspapers, and various other grassroots outreach efforts.  I can’t even start to express how excited I am to see all of this happening—keep up the great work; you’re making a major difference!

We have great momentum on achieving provider status. However, we still have much work to do.  With elections approaching in November, we are devoting the rest of the year to gaining more co-sponsors in the House of Representatives, getting a companion bill introduced in the Senate, growing the coalition to include a variety of other non-pharmacy stakeholders, educating members of Congress and the public, and supporting financially through PAC contributions the campaigns of political candidates that support provider status for pharmacists and the patients we serve.

Given that the 2014 legislative calendar is drawing to a close, we anticipate provider status bills being reintroduced in the next Congress starting in January 2015, and then re-doubling our efforts to get a bill passed and signed into law.  Admittedly, these are ambitious goals, but ASHP and our partners are committed to making provider status a reality for our patients in the coming years.

In September, we will be taking nearly 100 ASHP members to Capitol Hill as part of our annual Legislative Day to meet with their congressmen and senators to talk about the importance of increasing access to the patient care services of pharmacists, and to ask them to support H.R. 4190.  This demonstration of support will undoubtedly send a strong message that patients need greater access to pharmacists.

As I conclude this update, I want to say thank you to all of you—our members—for your selfless efforts on behalf of your patients.  Secondly, please keep reaching out to and educating your members of Congress about the vital roles you play in advancing healthcare and improving the lives of your patients.

If you haven’t written a letter to your member of Congress, please take a moment to do so through ASHP’s grassroots center.  It just takes a few minutes, and every letter and outreach effort makes a difference.  Also, if you have not yet made a contribution to the ASHP PAC, please consider doing so.  We’ve had the most successful political fundraising campaign ever in the history of ASHP, and it is making a difference with regards to our being able to support political candidates that support provider status.

I look forward to updating you again soon about our efforts to achieve provider status.  Until then, I hope you have a great summer!

July 16, 2014

Pharmacists Improve Diabetes Care

Pharmacists can positively impact patients who have type 2 diabetes, according to new research.

SAN DIEGO VETERANS WITH A LONG HISTORY OF TYPE 2 DIABETES are learning to take charge of their condition and make lasting improvements, thanks to coaching from a clinical pharmacist.

Candis M. Morello, director of the Diabetes Intense Medical Management (DIMM) clinic at the Department of Veterans Affairs (VA) San Diego Healthcare System, said in a phone interview that many veterans who are referred to the clinic have had diabetes for a decade or longer. Clinic patients have a glycosylated hemoglobin (HbA1c) level that exceeds 8% and suffer from other health problems in addition to their diabetes.

Morello called her work a personalized “tune-up” for these medically complex veterans.

During the initial 60-minute visit, Morello and the patient identify treatment and lifestyle goals and motivational strategies.

Morello said what motivates patients the most is “how many times they get up at night to go to the bathroom.”

“We’re talking five, six, eight times a night. I say, ‘How would you like to fix that? I can help you. And how would you like to fix that even within a few weeks, and start getting more energy? I can help you do that,’” she explained.

“It’s not your typical 20-minute primary care provider visit,” she said.

The DIMM clinic operates just four hours per week, and most patients need about three to five sessions with Morello before returning to their primary care provider for routine diabetes management.

Candice Morello

Candice Morello

According to data Morello presented in June at the American Diabetes Association scientific meeting in San Francisco, average HbA1c values over a six-month period fell by 2.4 percentage points among 85 DIMM clinic patients, compared with a 0.2-percentage-point decline among 51 primary care patients who were not referred to the DIMM clinic.

That translates to a three-year medical cost avoidance of $6412 per DIMM clinic patient and a return on investment of $7.81 per dollar spent on Morello’s services, she said.

Morello said she’s provided information about the clinic to VA staff and outside groups, and she would like to see the care model replicated elsewhere.

“There are so many [advantages] to this clinic that not only benefit the patient and the medical center but also benefit expanding the scope of other clinical pharmacists,” she said.

Morello, associate professor of clinical pharmacy and associate dean for student affairs at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, said she operates the DIMM clinic through a collaborative practice agreement with endocrinologist Robert R. Henry, chief of the VA San Diego Center for Metabolic Research and its section of endocrinology, metabolism, and diabetes.

Morello said the clinic was created to help the VA facility meet performance measures related to the care of more than 3000 patients with uncontrolled type 2 diabetes and to improve patients’ HbA1c values while avoiding hypoglycemia and weight gain.

To accomplish these goals, Morello uses the medication therapy management “spider web,” a teaching tool she developed and described in a publication last fall.1 The tool allows clinicians to assess medical, socioeconomic, and behavioral issues unique to each patient and incorporate these factors into a patient-centered care plan.

Among other things, Morello said, the spider web allows her to identify daily triggers in a patient’s routine, such as walking the dog or listening to a radio program, that the patient can associate with medication use and thereby improve adherence.

Morello emphasized that patients are in charge of their own daily care, and they learn skills to make good decisions about their medications and the habits that affect their glucose control.

“I tell them: I can’t be with you at the refrigerator. I can’t be with you when taking your medicine, I can’t be with you to say go take your dog for a walk. I can give you tools, I can help guide you, I can help direct you, but you’re the big decision-maker. And that totally resonates with them,” she said.

Morello said her veterans are spreading the word about their successes, and primary care physicians are also noticing the clinic’s work.

“I’m starting to see a shift as the primary care providers figure out how well their patients are tuned up by the time they get back,” she said. “They’re starting to send me patients who are just diagnosed or have only been diagnosed in [the past] three years or so.”

A primary care clinic that is part of the BHS Physicians Network, a private multispecialty group in San Antonio, Texas, has also reaped benefits from having a pharmacist onsite to help care for patients with type 2 diabetes.

Jodie Gee

Jodie Gee

Data from 118 patients showed an average drop of nearly four percentage points in HbA1c values for those whose care team included a pharmacist, compared with blood glucose values before the pharmacist was added to the practice, said clinical pharmacist Jodie Gee, who presented the findings at the American Diabetes Association meeting.

The addition of the pharmacist to the healthcare team also led to increases in the use of statins, low-dose aspirin, and angiotensin-converting enzyme inhibitors, said Gee, who spends half of her work hours at the BHS primary care clinic and the rest at the University of Texas at Austin College of Pharmacy, where she is a clinical assistant professor.

Gee initially sees her patients monthly in 45-minute sessions. She conducts a thorough medication review that includes medications for diabetes and the patient’s other conditions.

“We even have a lot of patients on inhalers, and we always check that inhaler technique,” she said.

The sessions also include a review of the patient’s blood glucose log and diet. For newly diagnosed patients, she reviews the pathophysiology of diabetes and helps them understand how their medications work and the importance of adherence.

Gee now works under a collaborative practice agreement with the three physicians in the primary care clinic, and she can initiate and adjust medications independently for patients with diabetes. But that wasn’t the case several years ago, when she came to the site to establish an experiential program for pharmacy students and residents.

“The physicians in the clinic, when I arrived, did not know what a Pharm.D. can do,” Gee said.

She said she started off teaching patients how to use their glucometer and inject their insulin. Then she gradually demonstrated to the physicians the value of performing medication reconciliations while gaining the practice members’ confidence in her ability to actively manage patients.

“Once they realized how much of a help it was, they started actually referring to me more patients,” she said. “Eventually, we got the collaborative practice set up, so now they say, ‘Go see Dr. Gee.’”

When Gee started managing her patients, she saw them monthly until their HbA1c level was controlled and then released them to their physician’s care.

“But . . . once they’d been discharged from my service, they would always be re-referred because their A1c’s would go up again,” Gee said.

Now, she said, after patients get their blood glucose under control, they return periodically to see her and maintain their progress.

“And actually, that’s worked,” Gee said.

Gee said the biggest lesson she has learned in her work at the clinic is the importance of being personable and persistent and engaging with the other members of the ambulatory care team.

She encouraged other pharmacists who have an interest in ambulatory care practice to “go for it.”

“You can definitely show a benefit of having a Pharm.D. as part of a primary care team,” Gee said.

1. Morello CM, Hirsch JD, Lee KC. Navigating complex patients using an innovative tool: the MTM spider web. J Am Pharm Assoc. 2013; 53:530-8.

–By Kate Traynor, reprinted with permission from AJHP
(Aug. 1, 2014; volume 71, pages 1240-1242).

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